The threshold of admission glycemia as a predictor of adverse events in diabetic and non-diabetic patients with acute coronary syndrome

Stress hyperglycemia and poor outcomes in patients with ST-elevation myocardial infarction: a systematic review and meta-analysis

Background

Hyperglycemia, characterized by elevated blood glucose levels, is frequently observed in patients with acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). There are conflicting sources regarding the relationship between hyperglycemia and outcomes in STEMI patients. We aimed to compile evidence to assess the association between hyperglycemia and adverse outcomes.

Methods

We conducted a comprehensive search for articles on PubMed and Embase using search strategies which yielded 4,061 articles. After full-text screening, 66 articles were included for systematic review, and 62 articles were further selected for meta-analysis.

Results

The 66 included articles spanned the years 2005-2023. Of these, 45 articles reported admission blood glucose, 13 articles used HbA1c, and 7 articles studied fasting blood glucose. Most studies defined STEMI with primary PCI as their inclusion criteria. Mortality was the most often outcome reported related to hyperglycemia. Overall, 55 (83.3%) studies were at low risk of bias. Both admission and fasting blood glucose were significantly related to short- and long-term mortality after STEMI, with a pooled risk ratio (RR) of 3.02 (95%CI: 2.65-3.45) and 4.47 (95% CI: 2.54-7.87), respectively. HbA1c showed substantial association with long-term mortality (HR 1.69, 95% CI: 1.31-2.18)) with a pooled RR of 1.58 (95% CI 1.26-1.97). In subsequent analyses, admission hyperglycemia was associated with an increased risk of reinfarction (pooled RR 1.69, 95% CI 1.31-2.17), heart failure (pooled RR 1.56, 95% CI: 1.37-1.77), cardiogenic shock (pooled RR 3.68, 95% CI 2.65-5.11), repeat PCI or stent thrombosis (pooled RR 1.99, 95% CI 1.21-3.28), and composite major adverse cardiac and cerebrovascular events (MACCE) (pooled RR 1.99, 95% CI: 1.54-2.58).

Conclusions

Our study demonstrated that hyperglycemia has a strong association with poor outcomes after STEMI. Admission and fasting blood glucose are predictors for short-term outcomes, while HbA1c is more appropriate for predicting longer-term outcomes in STEMI patients.

Systematic Review Registration

PROSPERO 2021 (CRD42021292985).

Association of Multiple Glycemic Parameters at Hospital Admission with Mortality and Short-Term Outcomes in Acutely Poisoned Patients

The prognostic value of multiple glycemic parameters in poisoned patients was never assessed. We aim to explore the effects of glucose variability on short-term outcomes in nondiabetic and diabetic patients acutely poisoned with undifferentiated xenobiotics. We performed a prospective observational study in a tertiary center for toxicology in northeastern Romania. Over the course of 3 years, we included 1076 adults, older than 18 years, admitted for acute poisoning with a xenobiotic. The mortality rate was 4.1%. The admission blood glucose level (BGL) predicted mortality (OR 1.015, 95% CI 1.011–1.019, p < 0.001) and complications (OR 1.005, 95% CI 1.001–1.009, p 0.02). The mean glucose level (MGL) after admission (OR 1.007, 95% CI 1.000–1.013, p 0.034) and coefficient of glucose variability (CV) were predictive for complications (OR 40.58, 95% CI 1.35–1220.52, p 0.033), using the same multivariable model. The receiver operating characteristic curve (ROC) analysis revealed that BGL had good predictive value for in-hospital mortality (area under the curve (AUC) = 0.744, 95% CI = 0.648–0.841, p < 0.001), and complications (AUC = 0.618, 95% CI = 0.584–0.653, p < 0.001). In patients acutely poisoned with xenobiotics, the BGL, MGL and CV can be useful as mortality and short-outcome predictors.

Impact of Admission Blood Glucose on Coronary Collateral Flow in Patients with ST-Elevation Myocardial Infarction

In patients with acute myocardial infarction, glucose metabolism is altered and acute hyperglycemia on admission is common regardless of diabetes status. The development of coronary collateral is heterogeneous among individuals with coronary artery disease. In this study, we aimed to investigate whether glucose value on admission is associated with collateral flow in ST-elevation myocardial infarction (STEMI) patients. We retrospectively evaluated 190 consecutive patients with a diagnosis of first STEMI within 12 hours of onset of chest pain. Coronary collateral development was graded according to Rentrop classification. Rentrop 0-1 was graded as poor collateral development, and Rentrop 2-3 was graded as good collateral development. Admission glucose was measured and compared between two groups. Mean admission glucose level was 173.0 ± 80.1 mg/dl in study population. Forty-five (23.7%) patients had good collateral development, and 145 (76.3%) patients had poor collateral development. There were no statistically significant differences in demographic characteristics between two groups. Three-vessel disease was more common in patients with good collateral development (p=0.026). Mean admission glucose level was higher in patients with poor collateral than good collateral (180.6 ± 84.9 mg/dl versus 148.7 ± 56.6 mg/dl, resp., p=0.008). In univariate analysis, higher admission glucose was associated with poor collateral development, but multivariate logistic regression analysis revealed a borderline result (odds ratio 0.994, 95% CI 0.989-1.000, p=0.049). Our results suggest that elevated glucose on admission may have a role in the attenuation of coronary collateral blood flow in acute myocardial infarction. Further studies are needed to validate our results.

[Leuko-glycemic index as an in-hospital prognostic marker in patients with ST-segment elevation myocardial infarction]

INTRODUCTION

Blood glucose and white blood cell count on admission have demonstrated prognostic significance in patients with myocardial infarction; leuko-glycemic index, a recently proposed marker, still lacks enough knowledge about its value.

OBJECTIVES

To evaluate the leuko-glycemic index as a prognostic marker in patients with ST-segment elevation myocardial infarction.

METHODS

A retrospective study was carried out in 128 patients with ST-segment elevation myocardial infarction, who were admitted between January 2009 and October 2010 in the Intensive Care Unit of the Hospital Dr. Celestino Hernández Robau. Clinical and laboratory data were collected, including glucose and white blood cell count on admission, from which we calculated the leuko-glycemic index and we evaluated its prognostic value.

RESULTS

Patients who had a poor outcome such as death, major cardiac complications and failed-thrombolysis, showed higher values of leuko-glycemic index (P<.01), which was correlated with several variables such as Killip class, and heart rate on admission (P=.000). We obtained a cutoff point of 1.158, patients with higher values had 3 times higher probability of death and complications (odds ratio=3,0; IC 95%: 1,2-7,3; P=.005); so leuko-glycemic index was an independent predictor after multivariate analysis.

CONCLUSIONS

The leuko-glycemic index was associated with an increased occurrence of hospital complications, death and failed-thrombolysis; its pathological value was an independent predictor of in-hospital death and complications in the studied sample.